CurrentModa HealthPolicy N/A

Moda Health Medicare Supplement Plan — High-deductible G with Vision and Hearing

Describes coverage, benefits, definitions, enrollment rights, and administrative provisions for Moda Health Medicare Supplement Plan High-deductible G (with optional vision and hearing rider) for subscribers; governs plan terms, renewability, premiums, and member resources.

Policy Summary

PayerModa Health

PolicyMedicare Supplement Plan — High-deductible G with Vision and Hearing

Policy CodePolicy N/A

Change TypeNo material changes (routine review)

Effective DateN/A

Next Review DateN/A

Key ActionProviders must file claims with Medicare first and notify Moda Health after Medicare payment so the plan can process secondary payment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

$2,870calendar year deductible

$250foreign emergency deductible

$50,000foreign emergency lifetime max

365 daysadditional inpatient days (max)

30 daysright to examine/return

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Plan Coverage and Benefit Criteria

Plan High-deductible G coverage criteria

Benefits payable after deductible and when Medicare conditions are met:

ALL of the following

The subscriber has met the calendar year deductible of $2,870. This deductible includes the Medicare Part A deductible and the subscriber's payment of the Part B deductible (but does not include the Plan's separate foreign travel emergency deductible).
Benefits apply to charges that are Medicare eligible expenses and are subject to the same conditions and exclusions that apply under Medicare (Core and Additional Benefits as described in Sections 3.1 and 3.2).
Services (inpatient stays or outpatient care) must occur on or after the policy effective date as specified in the applicable benefit section.

Core Benefits include: Part A hospital coinsurance for days 61–90; Part A lifetime reserve day coinsurance; 100% of Medicare Part A eligible hospital expenses after Medicare hospital benefits are exhausted (up to 365 additional inpatient days lifetime); first 3 pints of blood per calendar year; Part B coinsurance/copayment after the Part B deductible; and Part A hospice/respite coinsurance amounts.

Additional benefits include: the Medicare Part A inpatient hospital deductible; 100% of Medicare Part B excess charges; skilled nursing facility coinsurance for days 21–100 per benefit period; and medically necessary emergency care in a foreign country at 80% after a $250 calendar year deductible (limited to a $50,000 lifetime maximum).

Hospital care

Hospital care payment conditions

ALL of the following

The hospital stay must begin on or after the effective date of the policy.
The stay must be covered under Part A of Medicare during a benefit period.
When Medicare benefits are exhausted: If all Medicare hospital benefits are exhausted, the Plan will pay eligible expenses for up to an additional 365 days of inpatient hospital care.
The service provider must accept the Plan's payment as payment in full and may not bill the subscriber for any balance.

If the hospitalization goes past Medicare's 90 days in a benefit period, use of Medicare's lifetime reserve days is recognized as described in Section 4.1.

Medical care

Medical care (Medicare Part B eligible) payment conditions

ALL of the following

Medicare Part B must have paid a portion of the expenses when required by the Plan.
Inpatient medical care must occur during a stay that began on or after the effective date of the policy; outpatient medical care must be received on or after the effective date of the policy.

The Plan pays the Part B coinsurance/copayment after the Medicare Part B deductible has been met, consistent with the Core and Additional Benefits in Section 3.

Skilled nursing facility

Skilled nursing facility stay payment conditions

ALL of the following

The skilled nursing facility stay must be covered under Part A of Medicare during a benefit period.
The SNF stay must begin within 30 days after an inpatient hospital stay of the required length.
If admitted to a skilled nursing facility more than once in a benefit period, the confinement must be for the same condition as the first stay in that benefit period.
Both the hospital and the skilled nursing facility stay must start while the subscriber is covered under the Plan.

The Plan covers SNF coinsurance amount for days 21–100 per benefit period as an Additional Benefit (see Section 3.2).

Foreign emergency care

Emergency medical care in foreign countries

ALL of the following

While on a trip outside the United States, the subscriber needs emergency care. Emergency care means care needed immediately because of an injury or an illness of sudden or unexpected onset.
The emergency medical care is not eligible for payment under any Medicare program.
The emergency hospital, physician or medical care received in the foreign country would have been covered by Medicare if provided in the United States.
The emergency medical care begins during the first 60 days of a trip outside the United States.
The emergency medical care lifetime maximum of $50,000 has not been reached.

Vision rider

Vision services rider coverage and exclusions

ALL of the following

Routine vision services must be received from Vision Service Plan (VSP) Advantage network providers; members must identify themselves as VSP members so the Advantage network doctor will obtain benefit authorization from VSP.
Routine coverage: Covered routine vision services include one complete eye exam annually (including refraction); one pair of corrective lenses every 2 years (specified lens types); one pair of frames from the Genesis Eyewear Collection every 2 years (with $50 retail allowance outside collection); and prescription contact lenses and fitting every 2 years in lieu of frames and lenses (up to $50).
Not covered: Excluded items include orthoptics/vision training, artistically painted or non-prescription contacts, replacement of lenses/frames/contacts, insurance policies for contact lenses, additional contact lens office visits, contact lens modification/cleaning, and refitting after the initial 90-day fitting period.

Hearing rider

Hearing services rider coverage and exclusions

ALL of the following

Members must see a TruHearing provider to receive the hearing benefit; TruHearing will assist members with provider selection and hearing aid choices.
Routine coverage: Covered services include one hearing exam and evaluation per year by a TruHearing provider; one TruHearing-branded Advanced or Premium hearing aid per ear per year; first year follow-up visits with purchase; a 60-day trial period; 3-year extended warranty; and 80 batteries per non-rechargeable aid.
Copayments: $699 per TruHearing Advanced aid and $999 per TruHearing Premium aid (two aids per year, one per ear).
Not covered: Excluded items include ear molds, hearing aid accessories, extra batteries, additional provider visits, hearing aids obtained outside TruHearing, and costs associated with loss and damage warranty claims.

Value-added services

Value-added services and access conditions

Available value-added services

Active&Fit Direct provides access to 16,000+ fitness centers and studios, digital resources, a $25 one-time enrollment fee and $28 monthly fee; ASH may modify program fees or features with 30 days' notice.
ChooseHealthy offers discounts on wellness products/services and access to no-cost online classes at no additional cost to members who access the Member Dashboard.
Assist America travel assistance services (medical consultation, foreign hospital admission assistance, emergency evacuation, lost luggage/document assistance, interpreter/legal referral, return/transport arrangements) are automatically available while traveling >100 miles from home or outside the U.S.; trips >90 days excluded; activation via Assist America contact details.
Toll-free 24-hour Nurse Advice Line is available at no additional cost to members for non-critical medical advice.

General exclusions and limitations

Limitations and exclusions

Exclusions

No benefits for short-term at-home assistance for activities of daily living (home health aide, homemaker, personal care aide, or nurse) for ADLs such as bathing, eating, ambulating, medication self-administration assistance, and dressing changes.
No benefits for stays, care, or visits for which no charge would be made to the subscriber.
No benefits are available for the Medicare Part B deductible.
No benefits for charges that are not covered expenses under the subscriber's Medicare plan, unless otherwise specifically stated.
No coverage for stays, services, supplies, or facilities provided by hospitals or institutions owned or operated by a national government unless payment is required by law.

Exclusions and limited coverage

Coverage exclusions and limits under the Plan include:

Exclusions and limited coverage (examples)

No benefits are provided for outpatient prescription drugs, except outpatient drugs covered by Medicare Part A for hospice care.
Only preventive services covered under Medicare Part B are eligible for benefits.
The Plan will not cover any injury or sickness for which the subscriber is entitled to benefits under workers' compensation or similar law.
Charges that are not covered expenses under the subscriber's Medicare plan are not covered unless specifically stated elsewhere in the handbook.

Benefit payment and member obligations

Operational rules affecting benefit payment and suspension related to third-party recoveries, coordination with Medicare/other plans, and interactions with Medicaid.

ALL of the following

If a motor vehicle insurance has not yet paid, Moda Health may advance benefits for healthcare expenses arising from a motor vehicle accident and retains the right to repayment from settlement, judgment or other payment that exceeds full compensation to the subscriber for accident-related injuries.
If Moda Health requires protection of its recovery rights, the subscriber may subtract a proportionate share of reasonable attorney fees from amounts repaid to Moda Health.

ALL of the following

The subscriber and their representatives must notify Moda Health in advance of any claim or lawsuit against a third party seeking recovery of damages, whether or not the subscriber seeks recovery of benefits paid by Moda Health.

Coding, Limits, and Key Financials

Medicare-aligned benefit categoriesmixed

No codes listed

Unnamed code placeholdermixed

Medicare-determined eligible chargesmixed

No codes listed

Plan calendar year deductible — $2,870

Plan calendar year deductible$2,870

Deductible includes Medicare Part A deductibleYes — satisfied when subscriber has accumulated $2,870 in Medicare‑eligible expenses, including Part A inpatient deductible

Includes subscriber payment of Part B deductibleYes — subscriber's payment of the Part B deductible counts toward the $2,870

Does not include foreign emergency deductibleForeign travel emergency deductible is separate and not included in the $2,870

Foreign emergency lifetime maximum — $50,000

Foreign emergency lifetime maximum

Provider and Member Action Requirements

Billing Rule

Payment condition — Medicare alignment

Benefits are payable for covered charges that are Medicare eligible expenses and are subject to the same conditions and exclusions that apply under Medicare.

Prior Authorization

Vision authorization via VSP

Members must identify themselves as VSP members when contacting an Advantage network doctor so the doctor will obtain benefit authorization directly from VSP.

Routine vision services must be received from VSP Advantage network providers.
Members may visit www.vsp.com or call 800-877-7195 to choose a provider.

Defined Terms and Interpretations

Approved Amount — definition

Approved AmountThe amount Medicare determines to be reasonable for a service covered under Medicare Part B; may be less than the actual charge

Source for many servicesApproved amount is often taken from a Medicare fee schedule assigning dollar values to covered services

Impact on paymentThe Plan references Medicare's approved amount when determining Medicare eligible expenses

Assignment — definition

AssignmentAn arrangement in which a physician or medical supplier agrees to accept the Medicare‑approved amount as full payment for Part B services

Medicare payment under assignmentMedicare usually pays 80% of the approved amount directly to the physician or supplier after the subscriber meets the annual Part B deductible; subscriber pays the other 20%

Policy Summary

PayerModa Health

PolicyMedicare Supplement Plan — High-deductible G with Vision and Hearing

Policy CodePolicy N/A

Change TypeNo material changes (routine review)

Effective DateN/A

Next Review DateN/A

Key ActionProviders must file claims with Medicare first and notify Moda Health after Medicare payment so the plan can process secondary payment.

SourceLink

On This Page

The emergency medical care deductible of $250 per calendar year has been satisfied.

The emergency medical care is received on or after the effective date of the policy.

Benefits are payable only to the subscriber in United States currency in an amount based on the bank transfer exchange rate in effect on the day the claim payment is processed in the United States.

Foreign emergency care is covered at 80% after the $250 calendar year deductible, subject to the $50,000 lifetime maximum (see Section 3.2).

Well-vision exams, lenses and frames, and elective contacts have $0 copayment where specified; certain allowances (e.g., up to $50 for contacts or retail frame allowance) apply as described by the rider.

Coverage allows up to two TruHearing Advanced or Premium hearing aids per year (one per ear) as specified by the rider.

IAP via Canopy offers confidential counseling (up to 3 sessions per incident), crisis counseling, legal consultations, financial coaching, and identity theft consultation per program terms.

ArrayRx discount card is available at no cost to members living in Oregon to provide potential prescription savings.

Value-added services complement the Medicare supplement plan but are not part of the insured benefits; Moda Health or program vendors may discontinue or modify services with prior notice (typically 30 days).

In no event will medical payment under the Plan duplicate any amounts payable under Medicare; services are eligible for only one type of benefit under the Plan.

Subscribers must cooperate to protect Moda Health's recovery rights, providing documents such as a Third Party Recovery Questionnaire and Agreement (signed by attorney if retained), medical records, settlement correspondence, pleadings, demands, settlement agreements, releases or judgments as requested.

ALL of the following

By accepting benefits, the subscriber agrees Moda Health may intervene in lawsuits or arbitration and may release to or obtain from other insurers/organizations any information needed to carry out recovery provisions, even without the subscriber's written authorization.
If the subscriber or their representatives fail to comply with notification or cooperation requirements, Moda Health may refuse to advance payment, suspend payment of benefits, or recover advanced benefits (with a motor vehicle accident exception for section 8.4.4).

ALL of the following

When Medicare is secondary, Plan benefits payable are determined as if Medicare Part A and Part B benefits had not been reduced.
Services are eligible for only one type of benefit under the Plan (no duplication); e.g., if a service is defined as skilled nursing facility care, it is reimbursed under that benefit only.

ALL of the following

Benefits and premiums will be suspended during a subscriber's entitlement to Medicaid for up to 24 months if suspension is requested within 90 days of becoming eligible for Medicaid; reinstatement is possible if requested within 90 days of losing Medicaid entitlement.
Subscribers have a 31-day grace period after a premium due date to pay subsequent premiums (coverage remains in force during the grace period); voluntary termination requires 30 days' written notice to Moda Health.
Moda Health has the right to recover payments made that were not required under the Plan from persons, other organizations, or insurance companies.

Moda Health maintains privacy/confidentiality practices and provides notices and contacts; additional non-discrimination and complaint processes are available to members.

Applies to emergency medical care received outside the United StatesBenefit lifetime maximum applies to foreign emergency care only

Benefit payable only if care would have been covered by Medicare if provided in the U.S.Yes — foreign emergency care must meet Medicare equivalence condition

Foreign emergency deductible — $250 per calendar year

Foreign emergency deductible$250 per calendar year

Applies to emergency medical care while on a trip outside the United StatesDeductible must be satisfied for foreign emergency benefits to be payable

Separate from the Plan calendar year deductibleYes — the foreign emergency deductible is distinct from the $2,870 calendar year deductible

Claim submission deadline — Claims must be submitted within 12 months from the date the expense was incurred.

Claim submission deadlineClaims must be submitted within 12 months from the date the expense was incurred

ExceptionAbsence of legal capacity is the only exception to the 12‑month filing limit

Provider filing requirementProvider must file claim with Medicare first; Moda Health must receive notification from Medicare carrier before Plan pays

Prior Authorization

Hearing authorization via TruHearing

Members must see a TruHearing provider to receive hearing benefits; the TruHearing provider will assist with hearing aid selection and authorization.

Call 844-516-1478 to choose an in-network audiologist or hearing instrument specialist.
TruHearing provides available hearing aid options and supports purchase/fitment.

Documentation Required

Secondary payer claim filing

Providers must file claims with Medicare first; Moda Health requires notification from the Medicare carrier of its payment before the Plan will pay secondary benefits.

If a bill is electronically filed it will indicate the claim was forwarded to the secondary Medicare payor.
Claims to Moda Health must include the Medicare Summary Notice when mailed.

Documentation Required

Out-of-country claim documentation

For out-of-country emergency or urgent care, the subscriber must provide patient/subscriber identifiers, a statement explaining where and why care was sought, a copy of the medical record (translated if available), itemized bills for each date of service, and proof of payment.

Provide patient and subscriber name, group and identification numbers.
Provide proof of payment (credit card/bank statement or cancelled check).

Documentation Required

Third-party claim notification and cooperation

Subscribers and their representatives must notify Moda Health in advance of any claim or lawsuit against a third party seeking recovery of damages and must cooperate with Moda Health, including signing required documents and providing medical records and settlement information.

Sign and deliver documents Moda Health reasonably requires (e.g., Third Party Recovery Questionnaire and Agreement); attorney must sign if retained.
Provide medical information, settlement correspondence, pleadings, demands, and settlement agreements, releases or judgments.

Documentation Required

Moda Health intervention and information exchange

By accepting Moda Health benefits the subscriber agrees Moda Health may intervene in lawsuits or arbitration to protect its recovery rights and may release or obtain necessary information without the subscriber's written authorization.

Moda Health may notify third parties or their insurers of its recovery rights.
Moda Health may release to or obtain from other insurers or persons any information needed to carry out third-party recovery provisions.

Denial Risk

Sanctions for noncooperation

If the subscriber or their representatives fail to comply with third-party recovery obligations, Moda Health may refuse to advance, suspend payment of, or recover advanced benefits (except for motor vehicle accident claims handled under the motor vehicle provisions).

Moda Health may notify providers that payments have been suspended and may not be paid.
This sanction applies to failure to notify, cooperate, or sign required documents.

Medicare terms — key definitions

Medicare Part A inpatient deductibleDefined as the amount normally due from a subscriber upon first admission to a hospital in each benefit period

Medicare Part B deductibleThe amount a subscriber must pay each calendar year before Part B pays benefits

Limiting charge / Part B excess chargeAmount a non‑participating physician may charge above the Medicare approved amount (up to 15%)

Benefit periodA way of measuring inpatient/hospital use; begins the day hospitalized and ends after 60 days out of facility; triggers Part A benefits and deductible rules

Rider — definition

Rider (vision & hearing)Optional vision and hearing benefits supplemental to the Plan; the rider is not guaranteed renewable

Rider statusRider is separate from core Plan coverage and may have its own terms and provider networks (e.g., VSP, TruHearing)

Emergency care — definition

Emergency care — general definitionCare needed immediately because of an injury or an illness of sudden or unexpected onset

Context of useUsed to determine eligibility for foreign emergency benefits when subscriber is on a trip outside the United States

Vision services rider — definition

Vision services riderSupplemental rider that pays for vision examinations and corrective lenses/frames through VSP Advantage network providers

Network and authorizationMembers must identify themselves as VSP members so the Advantage network doctor will obtain benefit authorization from VSP

Covered frequencyOne complete eye exam annually; lenses & frames covered every 2 years

Benefits — definition

Benefits — definitionAny amount paid by Moda Health, or submitted to Moda Health for payment to or on behalf of the subscriber, including provider bills, statements, or invoices

Requests for paymentProvider bills, statements or invoices submitted to Moda Health are considered requests for payment of benefits by the subscriber

Third Party — definition

Third Party — definitionAny person or entity responsible for the medical condition or its aggravation, including insurers and forms of liability or motor vehicle coverage

ExamplesIncludes uninsured/underinsured motorist coverage, premises med‑pay, PIP, workers' compensation, and other insurer types

Third Party Claim — definition

Third Party Claim — definitionAny claim, lawsuit, settlement, award, judgment, arbitration decision or other action against a third party by or on behalf of a subscriber

Includes rights to assert claimsCovers claims or any right to assert the foregoing on behalf of the subscriber

Third-party recovery / subrogation — summary

Third‑party recovery / subrogation rightsModa Health may advance benefits (e.g., for motor vehicle accidents), pursue repayment from settlements/judgments, and is entitled to reimbursement of amounts paid from recoveries

Subscriber obligationsSubscriber must notify Moda Health in advance of any third‑party claim or lawsuit and cooperate by providing records and signing recovery agreements; attorney must sign if retained

Consequences of noncooperationFailure to comply may result in Moda Health not advancing, suspending, or recovering advanced benefits (with specific motor vehicle provisions in 8.4.4)

Coordination of benefits / Non-duplication

Coordination of benefits / Non‑duplicationWhen Medicare is secondary, Plan benefits are payable as if Medicare Part A and B benefits had not been reduced

Single benefit ruleServices are eligible for only one type of benefit under the Plan (no duplication across benefit categories)